Dewlop. Mad. Child Neurol. 1975, 17, 89-102
Annotations IMPROVEMENTS IN HEALTH CARE METHODSof measurement for optimal health in western societies have become increasingly complex and difficult to define. Physical, intellectual, emotional and social elements are inextricably interwoven, and our criteria are to a varying extent subjective and empirical. It is clear that mere avoidance of childhood death, and estimations of traditional morbidity rates during the early years of life, are of themselves inadequate standards upon which to base comparisons of child health in advanced societies. IVAN ILLICH has suggested that infant mortality rates could theoretically become too low for a healthy society (the inference being that heavily handicapped individuals might be preserved for a pattern of life that was not worth living). There is no evidence to suppose that in the U K or the USA the irreducible minimum in infant mortality rate is even in sight; on the contrary, the very slow rate of fall during the last 15 years has left both countries with a considerably higher infant death rate than is found in much of Europe (see Table)'. The remarkable changes between 1960 and 1970 in the infant mortality rates of France and Japan must be of particular interest and concern to a country like the U K , which in 1960 was among the leaders in the health tables and in 1970 was overtaken and is now relatively low down the tables. How is it that during the last I5 years the U K has fallen so far behind? The reasons are complicated and include many social and economic factors not directly related to medical care, but the pattern of medical services provided must nevertheless play a considerable part. France introduced major changes in her medical services some years ago. MARGARET and ARTHUR WYNNhave made a particular study of this subject2. To look at their findings may be helpful. Since 1945 France has had a special organisation, Protection M a t e r n e l l e et It~funtile (P.M.I.), the primary interest of which has been the promotion of child health and care in the first year of life. Despite intensive efforts, French research showed in 1969 that 23 per cent of infants under one year of age were not receiving adequate health care. These underprotected infants were particularly concentrated in disadvantaged families. The cost of permanent disability originating in early life was estimated at E l 500 million annually, or 2.5 per cent of the gross national product (GNP). In 1970, legislation was initiated to provide 20 routine examinations of every child during the first six years of life, nine of which were to be concentrated in the first year of life. The intention was to design these as developmental examinations to identify those children who were neglected, ill-treated or in need of medical treatment. This legislation also introduced a critical sanction, namely that the continued payment of family allowance for every child was subject to proof that certain of the medical examinations had been undertaken-the initial examination on or before the eighth day of life and the examinations at nine months and two years of age. In practise, these examinations thereby became compulsory, especially for socially disadvantaged families. The intention of this legislation was to try to reduce the amount of disability arising from disorders of congenital or early childhood origin, by early diagnosis of handicap and the 89
DEVELOPMENTAL MEDICINE A N D C H I L D
NEUROLOGY. 1975. 17
provision of early treatment. Social workers were to have a stronger medical content in their training programme to enable them to identify and care for children who were neglected or ill-treated. The regular medical examinations would provide the opportunity for identification of such children. The medical details of each of the 20 routine examinations were left to subordinate legislations sponsored by the Ministry of Public Health and Social Security. Express reference was made to the inclusion of tests to identify central nervous disorders leading to mental, sensory or psychomotor disability of long duration. A first certificate of health was required by law to be completed not later than the eighth day of life. The certificate at nine months was designed to provide a comprehensive record of child health and handicap. Health education of parents also became a priority for the medical and social services. It is acknowledged that the resources to provide such a service would take some years to develop. The number of doctors in France had increased by 44 per cent between 1958 and 1969. A further 76 per cent increase is planned to take place between 1969 and 1982. During the same period, the number of trained paediatric nurses is to be increased fourfold to 14,000. Though the WYNN’Sreport is clearly of great interest to the departments of health in every country, and indeed to everyone concerned with the improvement of standards of child health, it leaves several important questions unanswered. First, the dramatic improvement in the infant mortality rate in France between 1960 and 1970 antedated the new legislation. Before we can understand the reasons for this improvement we need to know a great deal more about the socio-economic alterations as well as changes in the pattern of health and care for children provided on the continental side of la riianche during the last 25 years. Secondly, when it is stated that the number of paediatricians is to be increased in France, exactly what is meant? The answer must be of great interest and importance to the Child Health Services Committee of the Department of Health and Social Security (now sitting under the chairmanship of Professor Donald Court, who have the responsibility of making recommendations about the future child health services in England and Wales), and to the American Academy of Pediatrics and other establishments in the USA.What is meant in France by ‘paediatrician‘ ? The USA has family paediatricians in private practice, and hospital paediatricians. In the U K there are very few privately paid paediatricians; nearly all work for the National Health Service. Until April 1974 there were in the U.K. child health doctors employed by local (public health) authorities. Do we need to create an attractive and highly respectable career structure for child health medical officers, working mainly from health centres but with close relationships with family doctors and hospital paediatricians ? If we believe that the programme now planned in France has merit, then there would seem to be little doubt that such provision is absolutely essential. It is just not practical to believe that this volume of routine examinations of children could or would be carried out effectively by the present establishment of family doctors or by the small number of consultant specialist paediatricians at present available or likely to be trained during the next decade. We need to know a great deal more of the details of the French child health system. We also need to know what plans have been made to validate its work. It has now been in operation for four years; what lessons have already been learnt? The answers may be valuable for improving the health of children in countries all over the world. Royal Devon and Exeter Hospital Heavitree, Gladstone Road, Exeter EX1 2ED. F. S. W. BRIMBLECOMBE 90
A N N O I-AT IONS
TABLE Infant mortality rates: deaths in first year of life per I000 live births
____
Cbrrntrj, ~.
____
__-
Finland Denmark France Switzerland England and Wales USA Japan
I.
2.
1960
1965 1970 ~__~____
21.0
17.6 18.7 21.9 17.8
21.5
27.4 21.1
21.8 26.0 30.7
19.0 24.7
18.5
12.5 14.2 15.1
15.1 18.1
19.8 13.1
REFERENCES Weatherall, J. (1974) Personal comniunication. Wynn. M., Wynn, A . (1974) Tlw RiKlit oJ'Ewr.v Child to Healrli C a w . .A Study ofProlrrtioir of'ilie Yorrtlg ChiM iir France. Occasional Papers on Child Welfare No. 2. Lundon: Council for Children's Welfare.
HYPERNATRAEMIA: A PREVENTABLE CAUSE OF ACQUIRED BRAIN DAMAGE? HYPERNA-rRAEMlA(defined as a plasma sodium level greater than 150meq/l) has been shown to be the most common electrolyte abnormality in dehydrated infants with gastroenteritis'. It has been found in 47 (63 per cent) of 75 dehydrated babies whose illness was severe enough to warrant electrolyte measurement. 16 of the 75 infants (20 per cent) had plasma sodium values greater than 160meq/l.l FINBERG and HARRISON', in a review of seven years experience i n the management of infantile diarrhoea, reported a 25 per cent incidence of hypernatraemia. MACAULAY and B L A C K H A L L 3 found hypernatraemia in 30 of 100 patients with gastroenteritis. They also reviewed the literature and found the incidence to vary between 1 1 and 34 per cent in I I reports (it was 71 per cent in a single paper). Hypernatraemia is most commonly observed in gastroenteritis, but it may also complicate infections of the respiratory and urinary tracts. These illnesses are often accompanied by gastrointestinal symptoms and they may be more common causes of hypernatraemia than has been recognised hitherto. If this were only a common biochemical disorder needing correction, little interest might be excited. However, R A P O P O K first T ~ recorded the association between high plasma sodium levels and neurological symptoms in the absence of gross central nervous system pathology. Other workers2-3, 5 * confirmed these observations and FINBERG et published supporting experimental work. Clinical features of the acute stage include irritability. sleeplessness, increased muscle tone and a high-pitched 'cerebral' cry. Convulsions also occur, often during the period of therapy rather than at presentation. The cerebrospinal fluid has no characteristic abnormal features at this time. MORRIS-JONES et a / . Nfound neurological symptoms in 18 (36 per cent) of 50 hypernatraemic children, of whom 39 were aged less than one year. They also found that the likelihood of convulsions occurring was related to the degree of hypernatraemia. At plasma sodium levels less than 158meq/l, the risk was 10 per cent: at or above this concentration the risk was 71 per cent. Ten children (20 per cent) died and autopsy revealed cerebral oedema and haemorrhage in five; three of these children also had cerebral venous or sinus thrombosis. One further patient had extensive cerebral infarction. MACAULAY and WA.I-SON~ found neurological signs in 22 per cent of patients with plasma sodium 160meq/l or more, but only in 14 per cent of those whose sodium values were below this. G
91
Annotations IMPROVEMENTS IN HEALTH CARE METHODSof measurement for optimal health in western societies have become increasingly complex and difficult to define. Physical, intellectual, emotional and social elements are inextricably interwoven, and our criteria are to a varying extent subjective and empirical. It is clear that mere avoidance of childhood death, and estimations of traditional morbidity rates during the early years of life, are of themselves inadequate standards upon which to base comparisons of child health in advanced societies. IVAN ILLICH has suggested that infant mortality rates could theoretically become too low for a healthy society (the inference being that heavily handicapped individuals might be preserved for a pattern of life that was not worth living). There is no evidence to suppose that in the U K or the USA the irreducible minimum in infant mortality rate is even in sight; on the contrary, the very slow rate of fall during the last 15 years has left both countries with a considerably higher infant death rate than is found in much of Europe (see Table)'. The remarkable changes between 1960 and 1970 in the infant mortality rates of France and Japan must be of particular interest and concern to a country like the U K , which in 1960 was among the leaders in the health tables and in 1970 was overtaken and is now relatively low down the tables. How is it that during the last I5 years the U K has fallen so far behind? The reasons are complicated and include many social and economic factors not directly related to medical care, but the pattern of medical services provided must nevertheless play a considerable part. France introduced major changes in her medical services some years ago. MARGARET and ARTHUR WYNNhave made a particular study of this subject2. To look at their findings may be helpful. Since 1945 France has had a special organisation, Protection M a t e r n e l l e et It~funtile (P.M.I.), the primary interest of which has been the promotion of child health and care in the first year of life. Despite intensive efforts, French research showed in 1969 that 23 per cent of infants under one year of age were not receiving adequate health care. These underprotected infants were particularly concentrated in disadvantaged families. The cost of permanent disability originating in early life was estimated at E l 500 million annually, or 2.5 per cent of the gross national product (GNP). In 1970, legislation was initiated to provide 20 routine examinations of every child during the first six years of life, nine of which were to be concentrated in the first year of life. The intention was to design these as developmental examinations to identify those children who were neglected, ill-treated or in need of medical treatment. This legislation also introduced a critical sanction, namely that the continued payment of family allowance for every child was subject to proof that certain of the medical examinations had been undertaken-the initial examination on or before the eighth day of life and the examinations at nine months and two years of age. In practise, these examinations thereby became compulsory, especially for socially disadvantaged families. The intention of this legislation was to try to reduce the amount of disability arising from disorders of congenital or early childhood origin, by early diagnosis of handicap and the 89
DEVELOPMENTAL MEDICINE A N D C H I L D
NEUROLOGY. 1975. 17
provision of early treatment. Social workers were to have a stronger medical content in their training programme to enable them to identify and care for children who were neglected or ill-treated. The regular medical examinations would provide the opportunity for identification of such children. The medical details of each of the 20 routine examinations were left to subordinate legislations sponsored by the Ministry of Public Health and Social Security. Express reference was made to the inclusion of tests to identify central nervous disorders leading to mental, sensory or psychomotor disability of long duration. A first certificate of health was required by law to be completed not later than the eighth day of life. The certificate at nine months was designed to provide a comprehensive record of child health and handicap. Health education of parents also became a priority for the medical and social services. It is acknowledged that the resources to provide such a service would take some years to develop. The number of doctors in France had increased by 44 per cent between 1958 and 1969. A further 76 per cent increase is planned to take place between 1969 and 1982. During the same period, the number of trained paediatric nurses is to be increased fourfold to 14,000. Though the WYNN’Sreport is clearly of great interest to the departments of health in every country, and indeed to everyone concerned with the improvement of standards of child health, it leaves several important questions unanswered. First, the dramatic improvement in the infant mortality rate in France between 1960 and 1970 antedated the new legislation. Before we can understand the reasons for this improvement we need to know a great deal more about the socio-economic alterations as well as changes in the pattern of health and care for children provided on the continental side of la riianche during the last 25 years. Secondly, when it is stated that the number of paediatricians is to be increased in France, exactly what is meant? The answer must be of great interest and importance to the Child Health Services Committee of the Department of Health and Social Security (now sitting under the chairmanship of Professor Donald Court, who have the responsibility of making recommendations about the future child health services in England and Wales), and to the American Academy of Pediatrics and other establishments in the USA.What is meant in France by ‘paediatrician‘ ? The USA has family paediatricians in private practice, and hospital paediatricians. In the U K there are very few privately paid paediatricians; nearly all work for the National Health Service. Until April 1974 there were in the U.K. child health doctors employed by local (public health) authorities. Do we need to create an attractive and highly respectable career structure for child health medical officers, working mainly from health centres but with close relationships with family doctors and hospital paediatricians ? If we believe that the programme now planned in France has merit, then there would seem to be little doubt that such provision is absolutely essential. It is just not practical to believe that this volume of routine examinations of children could or would be carried out effectively by the present establishment of family doctors or by the small number of consultant specialist paediatricians at present available or likely to be trained during the next decade. We need to know a great deal more of the details of the French child health system. We also need to know what plans have been made to validate its work. It has now been in operation for four years; what lessons have already been learnt? The answers may be valuable for improving the health of children in countries all over the world. Royal Devon and Exeter Hospital Heavitree, Gladstone Road, Exeter EX1 2ED. F. S. W. BRIMBLECOMBE 90
A N N O I-AT IONS
TABLE Infant mortality rates: deaths in first year of life per I000 live births
____
Cbrrntrj, ~.
____
__-
Finland Denmark France Switzerland England and Wales USA Japan
I.
2.
1960
1965 1970 ~__~____
21.0
17.6 18.7 21.9 17.8
21.5
27.4 21.1
21.8 26.0 30.7
19.0 24.7
18.5
12.5 14.2 15.1
15.1 18.1
19.8 13.1
REFERENCES Weatherall, J. (1974) Personal comniunication. Wynn. M., Wynn, A . (1974) Tlw RiKlit oJ'Ewr.v Child to Healrli C a w . .A Study ofProlrrtioir of'ilie Yorrtlg ChiM iir France. Occasional Papers on Child Welfare No. 2. Lundon: Council for Children's Welfare.
HYPERNATRAEMIA: A PREVENTABLE CAUSE OF ACQUIRED BRAIN DAMAGE? HYPERNA-rRAEMlA(defined as a plasma sodium level greater than 150meq/l) has been shown to be the most common electrolyte abnormality in dehydrated infants with gastroenteritis'. It has been found in 47 (63 per cent) of 75 dehydrated babies whose illness was severe enough to warrant electrolyte measurement. 16 of the 75 infants (20 per cent) had plasma sodium values greater than 160meq/l.l FINBERG and HARRISON', in a review of seven years experience i n the management of infantile diarrhoea, reported a 25 per cent incidence of hypernatraemia. MACAULAY and B L A C K H A L L 3 found hypernatraemia in 30 of 100 patients with gastroenteritis. They also reviewed the literature and found the incidence to vary between 1 1 and 34 per cent in I I reports (it was 71 per cent in a single paper). Hypernatraemia is most commonly observed in gastroenteritis, but it may also complicate infections of the respiratory and urinary tracts. These illnesses are often accompanied by gastrointestinal symptoms and they may be more common causes of hypernatraemia than has been recognised hitherto. If this were only a common biochemical disorder needing correction, little interest might be excited. However, R A P O P O K first T ~ recorded the association between high plasma sodium levels and neurological symptoms in the absence of gross central nervous system pathology. Other workers2-3, 5 * confirmed these observations and FINBERG et published supporting experimental work. Clinical features of the acute stage include irritability. sleeplessness, increased muscle tone and a high-pitched 'cerebral' cry. Convulsions also occur, often during the period of therapy rather than at presentation. The cerebrospinal fluid has no characteristic abnormal features at this time. MORRIS-JONES et a / . Nfound neurological symptoms in 18 (36 per cent) of 50 hypernatraemic children, of whom 39 were aged less than one year. They also found that the likelihood of convulsions occurring was related to the degree of hypernatraemia. At plasma sodium levels less than 158meq/l, the risk was 10 per cent: at or above this concentration the risk was 71 per cent. Ten children (20 per cent) died and autopsy revealed cerebral oedema and haemorrhage in five; three of these children also had cerebral venous or sinus thrombosis. One further patient had extensive cerebral infarction. MACAULAY and WA.I-SON~ found neurological signs in 22 per cent of patients with plasma sodium 160meq/l or more, but only in 14 per cent of those whose sodium values were below this. G
91
